Beloved Care Home

Based on record review and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for three of three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E1’s personnel record did not include documentation of completed training on fall prevention and fall recovery. Given E1's date of hire, this documentation was required. 2. A review of E2’s personnel record revealed documentation of completed fall prevention and fall recovery training conducted on December 15, 2023. However, E2’s personnel record did not include documentation of additional training on fall prevention and fall recovery. 3. A review of E3’s personnel record did not include documentation of completed training on fall prevention and fall recovery. Given E3's date of hire, this documentation was required. 4. In an interview, E4 acknowledged the facility failed to develop and administer a training program for all staff regarding fall prevention and fall recovery that included initial and continued competency training.

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution, for three of three personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E1's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E1's date of hire, this documentation was required. 2. A review of E2's personnel record revealed completed training on recognizing the signs and symptoms of TB on December 15, 2023. However, documentation of additional training was not available for review. 3. A review of E3's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E3's date of hire, this documentation was required. 4. In an interview, E4 acknowledged E1's, E2's, and E3's personnel records did not include documentation of initial and annual training on recognizing the signs and symptoms of TB.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for three of three personnel sampled. The deficient practice posed a risk if E1, E2, and E3 were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C) states, "Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person’s fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee." 2. A review of E1's personnel record revealed documentation of professional references, however, documentation of the facility's good faith effort to contact previous employers was not available. 3. A review of E2's personnel record revealed documentation of professional references, however, documentation of the facility's good faith effort to contact previous employers was not available. 4. A review of E3's personnel record revealed documentation of professional references, however, documentation of the facility's good faith effort to contact previous employers was not available. 5. A review of the E1's personnel record revealed documentation of a valid fingerprint clearance card (FPCC). However, the status of E1's FPCC was not verified as required. 6. A review of the E2's personnel record revealed documentation of a valid FPCC. However, the status of E2's FPCC was not verified as required. 7. A review of the E3's personnel record revealed documentation of a valid FPCC. However, the status of E3's FPCC was not verified as required. 8. A review of E1's personnel record did not include documentation of verification that E1 is not on the adult protective services registry. 9. A review of E2's personnel record did not include documentation of verification that E2 is not on the adult protective services registry. 10. A review of E3's personnel record did not include documentation of verification that E3 is not on the adult protective services registry. 11. In an interview, E4 acknowledged the facility did not ensure compliance with A.R.S. § 36-411.

Based on observation, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk if the individuals were not trained to provide the required services. Findings include: 1. While on-site for the compliance inspection, the Compliance Officer observed E3 at the facility, providing services to residents without supervision. 2. A review of E3's personnel record revealed E3 was hired as an assistant caregiver. E3's personnel record did not contain documentation of a completed caregiver training program. 3. In an interview, E4 reported E3 had just begun working at the facility. E1 acknowledged E2 interacted with residents not under the supervision of a manager or caregiver.

Based on observation, documentation review, record review, and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided health services for two of three personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include: 1. While on-site for the compliance inspection, the Compliance Officer observed E2 and E3 at the facility, providing services to residents. 2. A review of the facility's policies and procedures revealed a policy titled "Applicant and Employee Requirement Policy and Procedure." The policy stated, "Upon being hired by the facility the applicant must: Verification of qualifications, knowledge, and skills to perform the duties of the job hired for." 3. A review of E2's and E3's personnel records did not include documentation of the verification of E2's and E3's skills and knowledge. 4. In an interview, E4 acknowledged verification of skills and knowledge was not documented in E2's and E3's personnel records before E2 and E3 provided health services. This is a repeat deficiency from the on-site compliance inspection conducted on April 14, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for three of three personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E1's personnel record revealed a negative TB skin test that was more than 12 months old; however, no additional documentation of freedom from infectious TB was available for review. Based on E1’s date of hire, this documentation was required. 4. A review of E2's personnel record revealed a negative TB skin test that was more than 12 months old; however, no additional documentation of freedom from infectious TB was available for review. Based on E2’s date of hire, this documentation was required. 5. A review of E3's personnel record did not include documentation of E3's freedom from infectious TB. Based on E3's date of hire, this documentation was required. 6. In an interview, E4 reported E4 was unaware of the new TB policies as specified in R9-10-113. E4 acknowledged E1, E2, and E3 did not provide evidence of freedom from infectious TB as specified in R9-10-113.

Based on observation, record review, and interview, the manager failed to ensure that a caregiver received orientation that was specific to the duties to be performed by the caregiver before providing assisted services to a resident, for two of three personnel sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. While on-site for the compliance and complaint inspection, the Compliance Officer observed E2 and E3 at the facility, interacting with residents. 2. A review of E2's personnel record did not include documentation of a completed orientation before E2 began providing services at the facility. 3. A review of E3's personnel record did not include documentation of a completed orientation before E3 began providing services at the facility. 4. In an interview, E4 acknowledged E2 and E3 did not receive orientation that was specific to the duties to be performed by E2 and E3 before providing assisted services to a resident.

Based on observation, record review, and interview, the manager failed to ensure the facility did not retain an individual if the individual required restraints, including the use of bedrails, for one of two residents sampled. Findings include: 1. While on-site for the compliance inspection, the Compliance Officer observed R2's bed to be equipped with half bedrails. 2. A review of R2's medical record revealed a medication order dated March 17, 2023, that stated, "Use bedrail at night for falls prevention." 3. In an interview, E1 reported R2 required the use of bedrails overnight to prevent falls. E1 acknowledged the facility retained an individual who required restraints, including the use of bedrails.

Based on observation, record review, and interview, the manager failed to ensure that a resident was not subjected to restraint. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed R2’s bed to be equipped with half bedrails. 2. A review of R2's medical record revealed a medication order dated March 17, 2023, that stated, "Use bedrail at night for falls prevention." 3. In an interview, E4 reported R2 required the use of bedrails overnight to prevent falls. E4 also reported R2 was unable to make R2's needs known and lower the bed rails independently. E4 acknowledged R2 was subjected to restraint.

Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for two of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's and R2's medical record revealed R1 and R2 received medication administration. 2. A review of R1's medical record did not include a medication order for Quetiapine Fumarate 25 milligrams (mg), 1 tablet by mouth (po) daily (qd). 3. A review of R1's medication administration record (MAR) for March 2025 revealed R1 was administered Quetiapine Fumarate 25 mg, 1 tablet at 7:00 AM, March 1, 2025 - March 19, 2025, and March 24, 2025 - March 31, 2025. 4. A review of R2's medical record did not include medication orders for the following medications: Acetaminophen 500 mg, 3 tablets po three times a day (tid); Citalopram 20 mg, 1 tablet po qd; Dorzolamide 2% Solution, 2 drops twice a day (bid); Haloperidol 0.5 mg, 1 tablet po qd; Quetiapine 50 mg, 1 tablet po qd; Senna 8.6 mg, 1 tablet po qd; and Tamsulosin 0.4 mg, 1 capsule po qd. 5. A review of R2's MAR for March 2025 revealed R2 was administered the following medications March 1, 2025 - March 31, 2025: Acetaminophen 500 mg, 3 tablets po at 7:00 AM, 3:00 PM, and 7:00 PM; Citalopram 20 mg, 1 tablet po at 7:00 AM; Dorzolamide 2% Solution, 2 drops at 8:00 AM and 8:00 PM; Haloperidol 0.5 mg, 1 tablet po at 8:00 AM; Quetiapine 50 mg, 1 tablet po at 8:00 AM; Senna 8.6 mg, 1 tablet po at 7:00 AM; and Tamsulosin 0.4 mg, 1 capsule po at 7:00 PM. 6. In an interview, E4 acknowledged R1's and R2's medical records did not contain a medication order from a medical practitioner for each medication administered to R1 and R2.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of medication administered to the resident that included the name and signature of the individual who administered the medication, for two of two residents sampled. The deficient practice posed a risk if services provided could not be verified. Findings include: 1. A review of R1's and R2's medical records revealed R1 and R2 received medication administration. 2. A review of R1's medication administration record (MAR) for March 2025 revealed E4 administered all of R1's medications from March 1, 2025 - March 31, 2025. 3. A review of R2's MAR for March 2025, revealed E4 administered all of R2's medications from March 1, 2025 - March 31, 2025. 4. In an interview, E2 reported E2 administered medications to R1 and R2. However, documentation of administration by E2 was not available. 5. In an interview, E4 acknowledged that R1's and R2's medical records did not contain documentation of medication administered to the residents that included the name and signature of the individual who administered the medication.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a medication order dated February 28, 2025 for Trazodone 100 milligrams (mg) 1 tablet by mouth (po) at bedtime (qhs). 2. A review of R1's medication administration record (MAR) for March 2025, revealed R1 was administered Trazodone 50 mg, 1 tablet po at 8:00 PM March 1, 2025 - March 19, 2025 and March 24, 2025 - March 31, 2025. 3. In an interview, E4 reported R1 was administered 50 mg of Trazodone. 5. A review of R2's medical record revealed a medication order dated March 7, 2023, for Trazodone 100 mg, 1 tablet po as needed (PRN). 6. A review of R2's MAR for March 2025, revealed R2 was administered Trazodone 100 mg, 1 tablet po at 8:00 PM March 1, 2025 - March 31, 2025. 7. In an interview, E4 acknowledged medications administered to R1 and R2 were not administered in compliance with a medication order.

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. While on-site for the compliance inspection, the Compliance Officer requested R1's and R2's medical records with all required documents at approximately 9:15 AM. However, R1's and R2's medical records did not include documentation of medication administered to the residents in April 2025. 2. In an interview, E2 reported E2 had administered medication to R1 and R2 April 1, 2025 - present. However, E2 also reported E4 was the only personnel member to the facility's online medication administration record (MAR) system. 3. In an interview, E4 acknowledged the medications administered to R1 and R2 were not documented in R1's and R2's medical records.

Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice poses a health and safety risk to residents. Findings include: 1. While on-site for the compliance inspection, the Compliance Officer observed the following materials stacked precariously next to the facility's backdoor: A laundry hamper; A walker; A plastic three-drawer container; Wooden wall decor; A coffee table; A tarp; and Metal shelving. 2. The Compliance Officer observed the following materials leaning against the side of the facility's external wall: A wooden nightstand; An air mattress; A discarded wood panel; A plastic storage tote; Hanging wooden wall decor; and A discarded mop handle. 3. The Compliance Officer also observed the following materials stacked precariously along the facility's external wall: A dog kennel; A patio table, missing a top; Portable commodes; Shower chairs; An exercise bike; and Living room chairs. 4. In an interview, E4 acknowledged the premises and equipment used at the facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury. This is a repeat deficiency from the on-site compliance inspection conducted on April 14, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the following materials stored in the facility's unlocked laundry room: Cloralen Bathroom Cleaner with Bleach; Febreeze Fabric Softener; Windex Glass Cleaner; Pledge Wood Cleaner; A Great Value Air Freshener; Hot Shot Insect Killer; Stem Ants, Roaches, and Spider Spray; MicroGold Dual-Action Disinfectant & Antimicrobial Spray; Cloralen No-Splash Bleach; Valspar Signaure Paint; Two containers of Behr Paint; and Minwax Wood Stain. 2. In an interview, E4 acknowledged the toxic materials stored by the facility were not maintained in a locked area and were not inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on April 14, 2023.